LIBRARY
OF THE
MASSACHUSETTS INSTITUTE
OF TECHNOLOGY
Factors Influencing the Effectiveness of Health Teams
by
Irwin M. Rubin and Richard Beckhard
M.I.T. Working Paper
//
561-71
October, 1971
MASSACHUSETTS
INSTITUTE OF TECHNOLOGY
50 MEMORIAL DRIVE
CAMBRIDGE, MASSACHUSETTS 021
MASS. INST. TEChI
I
1
I
Factors Influencing the Effectiveness of Health Teams
by
Irwin M. Rubin and Richard Beckhard
M.I.T. Working Paper
//
561-71
October, 1971
The action-research intervention discussed in this paper
was carried out at the Dr. Martin Luther King Jr. Health
Center in the Bronx, New York. The effort was supported
through grants from Montifiore Hospital and the Carnegie
Corporation.
This paper will be published in the Milbank Quarterly and
should not be quoted in any part without permission from
the authors.
OCT 21 1971,
DEWEY LIBRARY J
nd 5^1-71
Dewey
SEP 101975'
RECEIVED
OCT 21
M.
I.
T.
1971
UbKArtitS
Group practice in health care delivery takes many forms.
The term
"group practice" usually refers to a group of colleague professionals who
combine their resources in delivering treatment care to a patient population.
Some of these groups are actively involved in preventive medicine efforts.
Because of hea-vy work loads, more and more activities are being delegated
to nurses, physicians assistants,
health workers.
and, in some cases, community based family
One common condition in all of these settings is that a
group is doing the
"
practicing ."
The effectiveness of any group in any setting is related both to its
capabilities to do the work and its ability to manage itself as an interde-
pendent group of people.
The central focus of this paper will be upon the
internal dynamics involved when a collection of individuals attempt to function
as a group.
Our objective is to provide a framework which will facilitate
consideration of several important issues involved in the more effective
utilization of groups in delivering health care.
We will begin by drawing upon the general body of knowledge about groups
and their dynamics developed within the behavioral sciences.
Several key
variables known to be of prime importance in any group situation will be
discussed.
Next, we will discuss the particular relevance of these variables
to group medical practice.
Third, we will draw upon our own experience in helping several health
teams improve their effectiveness.
The setting for this effort was a
community health center, located in a low income urban area, concerned with
providing comprehensive family centered health care using health
633180
C5I
-2-
teams
1
as the
main
II
delivery system."
--^
„_J:
"''
2
We will then discuss some issues which we feel apply to a variety of
health care delivery settings, where groups are collaborating on the
delivery.
Finally, we will indicate some issues for the education and training
of health workers who will be functioning in groups.
THE DYNAMICS OF GROUPS
In this section, we will present and briefly define, seven selected char-
acteristics or variables known to be of importance in any group situation.
Each characteristic can be viewed as a scale or yardstick against which one
can ask the question: is this particular group (made up of certain kinds of
people, trying to do a given task in this situation) located where it needs
to be on each of these scales to function most effectively?
Goals or Mission
A team or group has a purpose
.
There exists a reason (or reasons) for
the formation of the group in the first place.
In any group, therefore, there
will be issues like:
1. The "average" team in this center consisted of a full-time internist,
a full-time pediatrician, 2 full-time nurses, and 4-6 full-time family health
workers drawn from the community. Available on a part-time basis were a
dentist, a psychiatrist, in addition to the back-up support of x-rays, labs,
and the like. A team was responsible for 1500 families in a particular geographical area.
2. We pay little attention in this paper to the very important question
of the organization of which the health team is a part.
For an intensive discussion of the organizational issues involved in the delivery of health care
see Beckhard, R.
"The Organizational Issues in Team Delivery of Health Care,"
in this same volume.
,
3. For an excellent and readable description of group process, see
Schein, E. H. , Process Consultation , Reading, Mass., Addi son-Wesley, 1969.
For a more general introduction to the field of organizational psychology see
Schein, E. H. , Organizational Psychology , Englewood Cliffs, New Jersey,
Prentice-Hall, Inc., 1965.
-3-
who sets the goals?
(a)
how clearly defined are the goals?
(b)
how much agreement is there among members concerning the goals?
how much commitment?
(c)
how clearly measurable is goal achievement?
(d)
how do group goals relate to broader organizational goals?
personal goals?
to
Since a group's very existence is to achieve some goal or mission, these issues
are of central importance.
Role Expectations - Internal
In working to achieve their goals, group members will play a variety of
roles
.
There exists among the members of a group a set of multiple expectations
concerning role behavior.
Each person, in effect, has a set of expectations
of how each of the other members
its goals.
a)
4
should behave as the group works to achieve
In any group, therefore, there exists questions about:
the extent to which such expectations are clearly defined and communi-
cated (role ambiguity)
b)
the extent to which such expectations are compatible or in conflict
(role conflict)
c)
and, the extent to which any individual is capable of meeting these
multiple expectations (role overload).
These role expectations are messages "sent" between the members of a
group.
Generally, the more uncertain and complex the task, the more salient
are issues of rol?6 expectations.
4. For an excellent study of this concept of role sets see, Kahn, R. N.
et al Organizational Stress: Studies in role conflict and ambiguity
New
York, Wiley, 1964.
,
.
Role Expectations - External
Any individual is a member of several groups.
Each group of which he is
a member has expectations which can influence his behavior.
The Director of
Pediatrics in a hospital, for example, is "simultaneously" the manager of
of the funchis group, a subordinate, a member in a group of peers (Directors
tional areas), a member of a hospital staff, a father, husband, etc.
Each of these "reference" groups, as they are called, holds expectations
of a person's behavior.
overload.
Together they can be ambiguous, in conflict, or create
--
These multiple reference group loyalties can create significant prob-
lems for an individiial in terms of his behavior as a member of a particular
group.
While the source of the conflicts involved in the question of reference
group loyalties is external to a particular group, they can have significant
internal effects.
Decision-making
A group is a problem-solving, decision-making mechanism.
This is not tc
imply that an entire group must always make all decisions as a group.
The
issue is one of relevance and appropriateness; who has the relevant information
and who will have to implement the decision
.
A group can choose from a
range of decision-making mechanisms including decision by default (lack of
group response), unilateral decision (authority rule), majority vote, consensus,
or unanimity.
Each form is appropriate under certain conditions.
Each will have different
consequences both in terms of the amount of information available for use in
making the decision, and the subsequent commitment of members to implement the
decision.
Similarly, when a group faces a conflict it can choose to (a) ignore it,
(b)
smooth over it, (c) allow one person to force a decision, (d) create a
-5-
compromise, or (e) confront all the realities of the conflict (facts and
feelings) and attempt to develop an innovative solution.
The choices it
makes in both of these areas will significantly influence group functioning.
Communication Patterns
If, indeed, a group is a problem-solving, decision-making mechanism, then
the effective flow of information is central to its functioning.
Anything which
acts to inhibit the flow of information will detract from the group effectiveness.
At a very
There are a range of factors which affect information flow.
Meeting space
simple level there are architectural and geographical issues.
can be designed to facilitate or hinder the flow of communication.
Geo-
graphically separated facilities may be a barrier to rapid information exchange.
There are also numerous more subtle factors.
Participation - frequency,
order, and content - may follow formal lines of authority or status.
High
status members may speak first, most, and most convincingly on all issues.
The
best sources of information needed to solve a problem will, however, vary with
the problem.
Patterns of communication based exclusively on formal lines of
status will not meet many of the group's information needs.
People's feelings of
freedom to participate, to challenge, to express opinions also significantly
affect information flow.
Leadership
Very much related to the processes of decision-making and communication
is the area of leadership.
To function effectively, a group needs many acts
of leadership - not necessarily one "leader" but many leaders.
People often
misinterpret such a statement as saying "good groups are leaderless."
is not the intent.
This
Depending on the situation and the problem to be solved,
different people can and should assume leadership.
The formal leader of a
group may be in the best position to reflect the "organization's" position on
a particular problem.
Someone else may be a resource in helping the formal
leader and another member clarify a point of disagreement.
of necessary acts of leadership
.
All are examples
It is highly unlikely that in any group
there will be one person capable of meeting all of a group's leadership needs.
Norms are unwritten (often untested explicitly) rules governing the be-
havior of people in groups.
They define what behavior is "good or bad,"
"acceptable or iinaccep table" if one is to be a functioning member of this group.
As such, they become very powerful determinants of group behavior and take on
the quality of laws - "it's the way we do things around here!"
when they are violated
is most clear
—
seat, joking reminders, are observable.
to expulsion
—
quiet
Their existence
uneasiness, shifting in one's
Repeated violation of norms often leads
psychological or physical.
Norms take on particular potency because they influence all of the other
areas previously discussed.
Groups develop norms governing leadership, influence,
communication patterns, decision-making, conflict resolution and the like.
herently, norms are not good or bad.
a
The issue is one of appropriateness
In-
—
particular norm help or hinder a group's ability to work.
These seven factors, then, are characteristics of any group situation.
a
does
particular group needs to be on each of these "yardsticks" is a function of
the situation.
health teams.
We turn now to look at these factors within the setting of
Where
The Dynamics of a Health Team
Our intention in this section is to look at these factors affecting
group functioning and to relate them to a group
total health care).
setting (community based,
The Center in which we have worked
is
situation from which we will draw examples and observations.
the particular
However, the
issues raised are, in our view, very broadly relevant.
Goals or Mission
A health team striving to provide "comprehensive family centered health
care" faces uncertainties substantially different from those one might find in
a hospital setting.
The goals
in a hospital are relatively clear: remove the
Success is measurable and clear.
gall stone, deliver the baby.
social factors of prime importance.
Seldom are
The thrust is curative and the emphasis
is medical.
The community oriented health teams we have studied experience considerable
uncertaintly over their mission.
"Comprehensive" means the team can not ignore
social problems and emphasize the "relative security and certainty" of medical
5. By group practice we mean situations wherein people are together over
long periods of time working on a common task. More temporary groups like the
group formed to do a particular operation in a hospital are not included in our
discussion. Even in many temporary groups, such as short duration task forces
or committees, many of the process factors discussed can be observed to be in
operation.
6. For a more detailed preliminary report of our activities in this setting
see: Fry, R.E. and Lech, B.A,
An Organizational Development Approach to Improving the Effectiveness of Neighborhood Health Care Teams: A Pilot Program
Unpublished Masters thesis, Sloan School of Management, M.I.T., June 1971.
(copies available from Dr. Martin Luther King, Jr. Health Center, 3674 Third
Avenue, Bronx, New -York 10456).
,
7. If one takes a total hospital as a group, many similar issues appear.
Revens, for example, argues that the central task in a hospital is the
management of anxiety. This is very analogous to the position we take vis a vis
a health team.
The only difference is that the problems are more visible in
the smaller social system of an on-going group.
See Revens, R.W., Standards
for morale: cause and effect in hospitals , London: Oxford University Press, 1964.
There is considerable anxiety generated because the team does not
problems.
really know when and if it is succeeding.
The questions of priorities and time
allocations become complicated; how does one decide between competing activities
in the absence of clearly defined goals?
A team member wonders if she should
spend one-half a day trying to arrange for a school transfer for a child or
should she see the other patients scheduled for visits.
No one member of the team has been trained to be knowledgeable in all
the areas required.
Yet, the complexity of the task demands that doctors be-
come involved in social problems; nurses become the supervisors of parapro-
fessional family health workers who are an integral part of the team; and these
community based family health workers become knowledgeable in diagnosing and
treating psychiatric problems.
This is not to say everyone should become an
'"---
expert at solving all problems. The requirements are for considerable information
collection, sharing, and group planning so that the team has all the available
information to deploy its total resources to the task.
The anxieties and frustrations created by the complexity of the task are
inevitable - an inherent part of providing "comprehensive" care.
g
A major
team dilemma is one of managing short vs. long run considerations - to give
itself short run security and direction while not losing sight of its long run
vague and global goal.
Role Expectations - Internal and External
The nature of the task
—
comprehensive family centered health care
demands a highly diverse set of skills, knowledge, backgrounds.
—
In creating
a team, many "cultures" are of necessity being mixed and asked to work together.
A very useful tool for diagnosing the forces impinging upon a team
For more detail, see Fry and
8.
is called life space or force field analysis.
Lech, op. cit. , and an article by Kurt Lewin,
and
in Bennis, W., Benne, K.
Chin, R.
The Planning of Change , New York: Holt, Rinehart and Winston, 2nd
edition, 1969.
,
,
,
-9-
As a result of educational background and training, the doctors are ac-
customed to being primary (if not sole) authority and most expert in medical
issues.
The specialist role for which they have been so well trained and which
is so appropriate in a hospital setting comes under pressure.
in addition to his specialist skills,
As a team member,
the doctor is asked to become more of a
He needs to teach other health workers some of his medical know-
generalist.
He also needs to learn from them more about the social problems facing
ledge.
the community and the character, mores, and values of the particular patient
population.
Doctors tend to maintain strong
speciality groups.
it will be for
psychological ties with their professional
The stronger these ties for a physician the more difficult
His sense of professionalism
him to develop needed team loyalty.
stems from these external reference groups.
The careful hospital-type workup
he has been so well trained to do may not be feasible or appropriate in the
face of the hectic schedule generated by large nmnbers of patients.
flict nay become one around "professional standards."
The con-
Comprehensive group practice
may require a redefinition of these standards and perhaps even the redefinition
of a professional.
Both the nurses and family health workers tend to bring a history of sub-
missiveness.
The nurses have been trained to be submissive to doctors.
In this
setting, nurses find themselves as coordinators of the work of a team including
doctors
—
a complete role reversal.
Family health workers in this case are -local
community residents,
who, after six months of clinical training, suddenly find themselves
defined as "colleagues" with middle class physicians.
a
They bring
deep concern for social problems coupled with the best understanding of
what will/will not work with patients (their friends and relatives!).
The
\
/
-10-
teain
needs their knowledge of the cultural norms of the community and their
commitment to social issues.
Their background and passive posture is often
a barrier to the realization of these expectations.
Whereas the nurses and doctors have a professional reference group, the
family health workers as yet have none.
The resulting feelings of "homeless-
ness" are heightened by their liason role at the interface between the team
and the community.
9
Their membership and acceptance in the community is
crucial to the team's ability to be of service.
They alone can serve to bridge
the cultural gaps which exist.
This set of conditions differs markedly from the hospital setting where
strong reference group loyalties and clearly defined role expectations are
common.
Behaviors learned during one's individual preparation are appropriately
applicable in the vast majority of situations.
Although professionals and
paraprofessionals work in the same organization, seldom, if ever, are they
asked to work in highly interdependent on-going stable groups.
A part of being a member of a highly interdependent team is the need to
develop new loyalties and learn how to do some new things - not anticipated
or covered during individual training.
In fact, it is very unlikely that,
in the face of the mission of providing "comprehensive family- centered health
care," clearly defined complete job descriptions will ever be feasible.
9. Such people have been called marginal men.
A foreman in a factory is
another example - caught between the management culture and the worker culture.
10. The very notion of a team approach to the delivery of health care may,
for example, force a redefinition of the norm of privacy between doctor and
patient.
The norm may need to be adapted to encompass team and patient.
11. Many organizations are realizing the needs for such fluid role relationships. A job is now viewed as "a man in action in a particular situation
at a particular moment."
Such "job descriptions" must be constantly renegotiated and updated to account for both changes in the man and the situation.
-11This reality puts great stress on a team's ability to learn and adapt by
itself.
In response to a particular problem,
the question can not be "Whose
job is it?" but may instead have to be "Who on the team is capable? or "Who
needs to learn how to handle this situation?"
Decision-making
The inherent uncertainties in its mission and the diverse mix of skills
represented on a health team suggest that decisions can seldom be appropriately
made in a routine, prograinmable, or unilateral manner.
This is in sharp con-
trast to the majority of cases in the hospital setting where there is the relative clarity and certainty of the goals and clearly defined roles and lines of
authority.
One difficulty in any on-going team is the need to differentiate a variety
of decision-making situations.
In an attempt to be "democratic and participa-
tive" a team might try to make all decisions by consensus as a team.
sents a failure to distinguish, for example,
(a)
This repre-
who has the information neces-
sary to make a decision, (b) who needs to be consulted before certain decisions
get made, and (c) who needs to be informed of a decision, after it has been
made.
Under certain circumstances, the team may need to strive for unanimity
or consensus - in other cases majority vote may be appropriate.
Perhaps the greatest barrier to effective deci si on -making in highly
interdependent health teams stems again from the "cultural" backgrounds of
team members.
Doctors are used to making decisions by themselves or in col-
laboration with peers of equal status
professionals.
—
other doctors or highly educated
At the other extreme, the community residents who work on the
team are used to being passive dependent recipients of others' decisions.
Yet many times, on a health team, the doctor and the community workers are
and must behave as peers - neither one possessing ail the information needed
-12-
to solve a particular problem or make a particular decision.
Furthermore,
there are many times when the doctor is the one who needs information held
by another health worker.
When a conflict develops, the required discussion
which will lead to consensus is difficult to achieve; forcing, compromise,
or decision by default may result.
Commitment to decisions is low with the
result being that many decisions have to be remade several times
we decided that last week!"
—
"I thought
or "Didn't we decide that you would do such and
such?"
The team approach to delivery of health care puts great stress on the need
for numerous and various inputs to many decisions.
When the decision-making
process is inappropriate, less information is shared, commitment is lowered,
'
and anxiety and frustration are increased.
Communication Patterns/Leadership
Issues of communication patterns and leadership can be handled together
for, as was true in the case of decision-making as well, the central theme is
one of "influence."
The leadership or influence structure
—
to which we
have all become so accustomed via our family, educational, and organizational
experiences and which is appropriate for say a hospital operating room, will
be incapable of responding to the diversity of issues with which a health
team must deal.
In this setting each member is a resource.
open channels to all the other members.
He must have
Because of the complexities in this
type of group, a number of communication norms are required: openness (leveling)
and a person-to-person relationship which has enough mutual trust to enable
each person to "tell it like it is."
Team practice can not work if roles talk to roles - a much more personal
mutual dependency is required.
Influence, communication frequency, and leader-
ship should be determined by the nature of the problem to be solved not by
]
.
-13-
hierarchical position, by seating position, educational background, or social
status.
With respect to leadership, in particular, the teams we have studied relied on the model they knew best
—
in this case
"
follow the doctor ."
Con-
tinued reliance on that model will result in an overemphasis on medical vs.
social issues, a lack of shared commitment to decisions (which doctors sometimes interpret as "lack of professional attitude")
,
and less than complete
sharing of information, all of which affect the task performance directly.
Norms
Much of what we have described is reflected in a group's norms
.
The
teams we have studied have exhibited several powerful norms:
(a)
"in making a decision silence means consent;"
(b)
"doctors are more important than other team members," - "we don't
disagree with them;" "we wait for them to lead;"
(c)
conflict is dangerous, both task conflicts and interpersonal disagree-
ments - "it's best to leave sleeping dogs lie;"
—
(d)
positive feelings, praise, support are not to be shared
(e)
the precision and exactness demanded by our task negate the opportunity
"we're all
'professionals' here to do a job."
to be flexible with respect to our own internal group processes
[this
may be a carry-over from the hospital operating room environment where
the last thing you need is an innovative idea as to how to do things
better!
The effects of these norms, and others like them, is to guarantee that a team
gets caught in a negative spiral.
12
While the norms are those of rigidity, the
12. It is in this regard that our thinking is very similar to Revens
The ineffective management of inherent anxiety results in more anxiety creating
a negative feedback loop and a self-reinforcing downward spiral.
See Fry and
'
Lech, op. cit.
-14-
complexity of the environment and the task to be done demand flexibility.
The frustrating, anxiety provoking quality of the task places great demands for
some place to recharge one's emotional battery.
The team is potentially such
a place.
In addition to these specific norms of flexibility, support, and openness
of communication, there are a set of higher order norms which are essential.
Task uncertainty and environmental changes require that a team develop a
capacity to become self-renewing
—
become a learning organism.
Learning
requires a climate which legitimizes controlled experimentation, risk taking,
failure, and evaluation of outcomes.
In the absence of norms which support
and reinforce these kinds of behaviors, a team will end up fighting two
enemies - its task and itself
.
There exists, in other words, a unique connection between what a team
does
[its task]
and how it goes about doing it [its internal group processes ].
At a very simple level, the health care analogy would be: if a team is to treat
a family as
an integrated vmit [its task], the team itself must, in many ways
operate as a highly integrated "family unit" [its internal group processes].
Without this ability to maintain itself a health team will, like many other
"pieces of equipment" eventually
bum
itself out.
In the interim, work con-
tinues to get done but more and more energy is demanded to "move the machine
forward."
To siimmarize, the internal process issues we have discussed will occur in
any group.
They can not be wished away or ignored for long without some cost.
Nor are they the result - as is frequently assumed - of basic personality
problems.
More often team members have difficulty functioning together because
of ambiguous goal orientations, unclear role expectations, dysfunctional
deci si on -making procedures and other such process issues.
•15-
If a health team is first to survive and second to grow,
it must,
as
we have said, develop an attitude and a capability for building and renewing
itself as a team.
It can do this first by becoming aware of how its internal
group processes influence
its ability to function and second by learning how
to manage these process or maintenance needs in a more productive manner.
We turn now to a brief case illustration of an effort aimed at helping health
teams move closer to this ideal of becoming self-renewing or learning organisms.
A CASE STUDY OF A HEALTH TEAM IMPROVEMENT EFFORT
13
Our efforts at helping teams improve their functioning relied heavily upon
a very simple but powerful model - the action research approach.
14
The basic
flow of activities can be depicted in the following manner:
Summarization
Data
Collection
and
Feedback
Action
Planning
Evaluation
In this setting, the initial activity with a health team involved inter-
viewing each member individually - using both open-ended questions and check
list ratings.
Questions asked related directly to the seven process factors
discussed earlier such as team goals, levels of participation, decision-making
styles, etc.
These data were then stmimarized and fed back anonymously to the
entire team.
13. Our initial efforts at intervening into two health teams are reported
We have to date completed initial interin detail in Fry and Lech, op. cit.
Similar activities are planned for other teams
ventions with six health teams.
in the future as well as follow-up activities to reinforce our initial efforts.
Four of our students, Ron Fry, Bern Lech, Marc Gerstein, and Mark Plovnick
have worked closely with us in these efforts.
—
14. For an excellent description of this model and its applicability in
a wide variety of situations see Beckhard, R. , Organization Development:
Strategies and Models
,
Reading, Mass: Addison-Wesley
,
1969.
-16-
Team members' reactions to the data presented during this feedback, session
were varied.
For some, the result was one of surprise
people felt that way about this team!"
their own concerns widely shared.
—
"I didn't realize
Others were surprised to find many of
Before the feedback session, many people
believed they were the only ones experiencing certain difficulties.
The most
frequent reaction could be characterized as follows: "These problems have been
—
around
under the surface
—
for a long time.
Now they have been collected,
summarized, and are out on the table for all of us to see."
The teams, in other words, were provided with an im^ge or picture of their
present state based on information (feelings as well as facts) collected from
the most valid sources available
of the interview feedback process
—
,
the team members themselves.
teams owned the information
were used to exemplify a particular issue
state
—
)
As a result
(Verbatim quotes
and shared the image of their present
"it's out on the table for all of us to see."
These two elements of
shared ownership helped to create a heightened desire and commitment on the part
of team members to solve their problems.
In order to cope with the large number of complex problems reflected in
the information and to move most effectively into action planning, the health
teams had to:
a)
prioritize the multiple issues reflected in their data;
b)
decide upon the most appropriate format to use (total group, homogeneous
vs. heterogeneous subgroups, etc.)
c)
to generate solution alternatives;
develop a clear and shared set of change objectives or goals
—
an
image of what a more ideal or improved state would be;
d)
allocate individual and subgroup responsibilities to implement chosen
actions;
e)
and, specify mechanisms and procedures for checking progress (follow-up).
-17-
The problem-solving skills, attitudes, norms, etc. needed to accomplish
the above "process work" were very similar to behaviors needed to successfully
accomplish "task work."
This unique connection between task and process can
be clarified with the following example.
A salient problem in each health team concerned their regularly scheduled
1
1/2 hour weekly team conference meetings.
These meetings represented the
one time each week when the entire team met together.
The intent was to discuss
patient family cases, learn from each other's experiences, work on common probllems and the like.
The pervasive feeling with regard to these meetings was one
of frustration and dissatisfaction.
time
They were dull, a waste of time, and a
for some people to "lecture" about their pet topics.
The way the team managed itself (its process) during these meetings
in fact made the situation more difficult.
The negative spiral to which we
referred earlier was operating to drain energy and commitment required to
solve patient problems.
The specific action plans developed and subsequent team improvement inter-
ventions were, in each case, a product of the particular issues reflected in
the data collected initially from a team.
Regardless of the problem, the same
action research model, with minor variations was applied.
For example, action
plans aimed at improving the team conference meeting included:
(a)
the formation of agenda planning committees;
(b)
systems of rotating chairmen to help all team members enhance their
skills at running a meeting;
(c)
designation of observers, on a rotating basis, to help the team evalu-
ate - at the end of each meeting - the impact of its own group dynamics.
15. In several cases, these observers were part of the next agenda planning
committee.
The data collected by the observers, in other words, was quickly
used as an input into the next action planning phase.
;
.
,
-18-
While many consultant interventions were aimed at helping a team to solve
problems it presently felt, longer run considerations also guided consultant
behavior.
Whenever feasible, a team was helped to see the connection between
what they were doing (their task) and how they were going about it (their
internal group process).
This expanded awareness helped to develop an attitude
(norm) toward change which legitimized managed experimentation and learning
.
In other words, if a team is to become self-renewing, it must be willing to
experiment ia a controlled way - to try new ways of working, evaluate and learn
from the consequences of these efforts
,
and use this new learning in the plan-
ning and implementation of future efforts.
On the assumption that the action
research approach we used represented a generalizable problem-solving model
we continuously worked to help the teams to internalize this model so that they
could apply it when confronted with future problems.
The short time frame within which we worked dictated limited and modest
objectives.
a)
Short run changes have been observed and documented in terms of:
greater work productivity, particularly with respect to team confer-
ence meetings
b)
increased clarity of role expectations plus mechanisms for negotiating
changes in role behavior as they are needed;
c)
greater flexibility in decision-making;
d)
and, more widely shared influence and participation between all team
members
.
19-
IMPLICATIONS FOR HEALTH TEAM OPERATIONS
Based on an uinderstanding of groups in general and our experiences with
health teams working in an urban community, several significant learnings are
beginning to emerge with implications for the delivery of health care using
groups or teams
(1)
Some conscious program which helps team members look, at their par-
ticular goals, tasks, relationships, decision-making, norms, backgroimds and
values is essential for team effectiveness.
a
It is naive to bring together
highly diverse group of people and to expect that, by calling them a team,
they will in fact behave as a team.
(2)
Behavioral science knowledge and techniques, developed in a variety
of non-medical settings are relevant and appear to be transferable to organi-
zations involved in the delivery of health care.
is one such example.
The action research approach
It reflects a methodology and set of values which can
help a team become a self-renewing organism.
team that it treat itself as a patient
—
In some ways, it demands of a
periodically diagnosing its own
state of health, prescribing medication, and subjecting itself to the followup check-ups to insure that the prescription is working.
Although this process
16.
It is ironic, indeed, to realize that a football team spends 40 hours
per week practicing teamwork for the 2 hours on Sunday afternoon when their
teamwork really coimts. Teams in organizations seldom spend 2 hours per year
practicing when their ability to function as a team counts 40 hours per week!
-20-
may require the assistance of a "third party" initially, the "patient team"
can learn to do many of the things itself.
(3)
Ideally, every team member can be a participant in the group's task
and an observer of the group's process.
At a minimum, such capability for
helping teams look at their own working should be built into the training of
team leaders.
(4)
The organizations in which health teams are Inlbedded will need to
develop an internal capability to help groups manage their own process.
Outside resources are appropriate to initiate such activities, but internal
specialists are needed to provide needed continuity, follow-up and reinforcement.
(5)
Programs need to be developed which focus specifically on the prob-
lems of helping people cope with cultural discrepancies whether these be be-
tween a team and its client population or between team members, e.g, the pro-
fesionally based physician and the community based family health worker.
(6)
Certain team members will need particular leadership skills
.
If
nurses are expected to act as team coordinators, they will need special
training.
All team members will need to develop membership skills
,
e.g.,
listening, collaborating.
(7)
Although some of this needed training may be accomplished during
17
individual preparation, some training needs to be done with the team as a
unit
.
In addition, more of this training needs to be goal related , e.g.,
treating a family as an integrated unit as compared to technique related ,
e.g., taking histories, doing EKG's.
(This does not imply that such skills
—
It is clear that existing educational and training institutions
medical
schools, nursing schools, teaching hospitals
will need to bear part of this
responsibility.
In addition to the content areas of psychology, social psychology, sociology, social anthropology and the like, increasing emphasis must
be placed in such areas as group dynamics, organizational behavior, social intervention, and the theory and process of planned change.
~
:
relation to specific
are unimportant - only that they should be learned in
goals).
(8)
The socialization of new team members needs to be examined.
Pro-
grams need to be developed which in fact orient a new family health worker,
for example, to her role as a team member as well as a specialist with par-
ticular skills.
(9)
There is great value in initiating team development activities, of
the kind we described, at the point of a team's formation.
dividuals, develop their own cultures or personalities.
Teams, like in-
In "older teams" a
considerable amount of unfreezing may have to take place before new changes
can be tried.
Early team development efforts would have several distinct
advantages
a)
the period of initial socialization has a very significant effect on
the team's future development
—
early experiences set a very strong tone
which influence future events;
b)
a group can more easily create the kind of culture, norms, procedures
it deems useful if it is starting fresh rather than having to "undo" a long
histoiry of past experiences;
c)
and, perhaps most important, would be the early recognition that the
team really has two equally important tasks
—
to deliver health care and to
continuously work to develop and maintain itself as a well functioning team in
order to improve its services.
-22-
The focus of this paper has been upon the working of existing health teams
in a community setting where entire families are "the patient."
We have
explored some ways in which one might help such a team (1) learn more about its
own "internal dynamics" and (2) use these learnings to continuously improve
the way it functions in delivering health care.
We will, in all likelihood, see an increasing number of models for
delivering health care in which groups of some form play an integral part.
The effectiveness of these groups in accomplishing their tasks will be, in
part, a function of how will they manage themselves with respect to the "process
variables" discussed in this paper.
JAN
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